The new US blood pressure guideline lowers the definition of high blood pressure to 130/80 mm Hg.The new guideline adopts a key component of the 2013 cholesterol guideline and incorporates overall cardiovascular risk. The AAFP has decided to not endorse the recent hypertension guideline because it gave undue importance to the SPRINT trial and cardiovascular risk which was not validated and would lead to overtreatment. The guidelines are discussed in this article.

In 2017, the American Heart Association updated the hypertension guidelines.[1] The major change was that systolic blood pressure of 130 mmHg or more or diastolic of 80 mmHg or more is considered hypertension and needs to be controlled [Table 1] and [Table 2]. Hence, persons with systolic blood pressure of 130–140 mmHg and/or diastolic 80–90 mmHg are now classified as hypertensive, while they were earlier classified as prehypertensive by Joint National Committee 7 criteria.[2] This relabels a large number of people as having elevated blood pressure and warranting lifestyle changes. The 2017 guideline also emphasizes individualized cardiovascular risk assessment. They use 10 year cardiovascular disease (CVD) risk calculation to decide on treatment threshold.[3] This will also mean that most elderly patients would get treated with medications earlier. Use of a risk calculator for blood pressure (BP) treatment may overestimate risk in many individuals and perhaps lead to overmedication. Whether a CVD risk calculator can decide when to treat hypertension is debatable.

The basic question is whether intensive treatment of hypertension is better than less aggressive approach. Although SPRINT trial showed it to be beneficial, ACCORD and Secondary Prevention of Small Subcortical Strokes trials did not find a significant benefit.[4],[5],[6] Greater emphasis seems to have been given to the SPRINT data in 2017 guidelines. Another aspect is that Stage 1 hypertension becomes a very narrow range and normal variability of blood pressure may make a person in and out of this stage [Figure 1]. It is common these days for patients to record blood pressure at home with oscillometric devices and to bring to the clinic a chart of those readings, some of which may be in Stage 1 and others in elevated blood pressure range. Narrowness of stages may make this classification difficult to implement.

The American College of Physicians has set the threshold for treatment at 150 mmHg for average-risk older (>60 years) people.[7] It was estimated that this new guideline would classify almost 46% of middle-aged Americans as hypertensive as compared to 32% as per the previous guidelines.[8] In addition, the prevalence of high blood pressure is expected to triple among men under the age of 45 years, and double among women under the age 45 of years and would result in almost 20 million of them getting started on medication. Other major guideline-making associations like the American College of Physicians/NICE/ESC have not as yet accepted this guideline.

Nonpharmacologic therapy: weight loss, sodium restriction, and potassium supplementation, increased physical activity, and restrict alcohol. Use of medications is recommended in patients with clinical CVD and an average systolic BP (SBP) ≥130 mmHg or a diastolic BP (DBP) ≥80 mmHg. Use of medication is also recommended for an SBP ≥140 mmHg or a DBP ≥90 mmHg.

Targets

For adults with confirmed hypertension and known CVD or 10-year atherosclerotic CVD (ASCVD) event risk of 10% or higher, a BP target of <130/80 mmHg is recommended. For adults with confirmed hypertension but without additional markers of increased CVD risk, a BP target of <130/80 mmHg is recommended as reasonable.

Principles of drug therapy

Initial therapy includes thiazide diuretics, calcium channel blockers (CCBs), and angiotensin-converting enzyme (ACE) inhibitors or angiotensin receptor blockers (ARBs). Two first-line drugs of different classes are recommended with Stage 2 hypertension. The primary change in recommendations regarding pharmacologic therapy is the elimination of beta-blockers from first-line therapy for patients with primary hypertension. For adults with confirmed hypertension and known stable CVD or ≥10% 10-year ASCVD risk, a BP target of <130/80 mm Hg is recommended.

The strategy is to first follow standard treatment guidelines for CAD, heart failure with preserved ejection fraction (HFpEF), previous myocardial infarction, and stable angina, with the addition of other drugs as needed to further control BP. In HFpEF with symptoms of volume overload, diuretics should be used to control hypertension, following which ACE inhibitors or ARBs and beta-blockers should be titrated to SBP <130 mmHg. Treatment of hypertension with an ARB can be useful for prevention of recurrence of atrial fibrillation.

Chronic kidney disease

BP goal should be <130/80 mmHg. In those with Stage 3 or higher CKD or Stage 1 or 2 CKD with albuminuria (>300 mg/day), treatment with an ACE inhibitor is reasonable to slow progression of kidney disease. An ARB is reasonable if an ACE inhibitor is not tolerated. In adults with acute intracranial hemorrhage and SBP >220 mmHg, it may be reasonable to use intravenous drug infusion to lower SBP. In acute ischemic stroke, BP should be lowered slowly to <185/110 mmHg before thrombolytic therapy.

Diabetes mellitus

Antihypertensive drug treatment should be initiated at ambulatory blood pressure ≥130/80 mmHg with a treatment goal of <130/80 mm Hg. In adults with diabetes mellitus and hypertension, all first-line classes of antihypertensive agents (i.e., diuretics, ACE inhibitors, ARBs, and CCBs) are useful and effective. ACE inhibitors or ARBs may be considered in the presence of albuminuria.

Age-related issues

Although the new guideline lowers the blood-pressure goal for people over 65 years, it suggests that 30-year-old and 80-year-old should have the same goal. Treatment of hypertension is recommended for adults (≥65 years of age), with an average SBP ≥130 mmHg with SBP treatment goal of <130 mmHg. In addition, the new guideline does not consider isolated systolic hypertension, which is a major problem among many people over 70 years. For older adults (≥65 years of age) with hypertension and a high burden of comorbidity and/or limited life expectancy, clinical judgment, patient preference, is reasonable for decisions regarding the intensity of BP lowering and choice of antihypertensive drugs.

Conclusion

The new guidelines in 2017 have mainly reset the treatment threshold to 130/80 mmHg. Most part of the guidelines summates the current knowledge on drug therapy and disease management along with the promotion of team-based system approaches for better diagnosis and management. Rather than advocate a specific target for all adults, the focus should be on choosing blood pressure targets that allow for “a choice based on a patient's risk profile, susceptibility to harms, and treatment preferences.”

Agreement between 2017 ACC/AHA Hypertension Clinical Practice Guidelines and Seventh Report of the Joint National Committee Guidelines to Estimate Prevalence of Postmenopausal Hypertension in a Rural Area of Bangladesh: A Cross Sectional Study